Being a Radical Doula

How pro-choice advocacy and birth activism go hand in hand.

By Miriam Pérez, Swarthmore College
Monday April 16, 2007

How can the same person be a pro-choice activist and a birthing-rights advocate devoted to supporting women through childbirth? When I became interested in the rights of pregnant and birthing women in college, I never imagined there was a contradiction between my pro-choice politics and my newfound passion for midwifery. But a few months ago, Lynn Paltrow, executive director of the National Advocates for Pregnant Women, clued me into a longstanding divide between the pro-choice and birthing communities. She and her organization put together a groundbreaking conference that attempted to bridge the gap between these two groups, who rarely talk about each other’s issues.

Abortion had never been addressed at the midwifery conferences I had attended, and the issue gets little mention on the websites of the most prominent midwifery and doula organizations. (A doula is a person trained to provide support to women in labor.) Initially these silences led me to believe that birth activists held my pro-choice beliefs, but I recognize now that they are actually a sign of discord. Rather than address what can be a controversial topic (particularly for a movement that includes religious midwives and doulas), most birthing rights advocates choose to avoid the topic of abortion entirely. With a confirmed focus on the pregnant woman and her journey toward birth, such a high value can be placed on motherhood that it becomes difficult to condone practices like abortion. Similarly, within the pro-choice movement, such a large emphasis is placed on the rights of women not to parent that one can forget about the rights of women who choose to parent.

When I was thrust into the world of what I call “birth activism,” I approached the issues with my usual attitude: People who didn’t get it just didn’t have the facts yet. They hadn’t seen what I’d seen or read what I had read about how terrible the current state of childbirth is in the United States, particularly in the hospital setting. The documentary “Born in the USA” plainly demonstrates how much better midwives and out-of-hospital settings are for low-risk births, and how the bureaucratic obstetrics ward contributes to a landslide of unnecessary medical interventions that aren’t good for mothers or children. Childbirth in its current form—attended by an obstetrician in the hospital—has only existed since the 1920s. Before that time, midwifery care in the home was the standard practice. According to author Karla Hay, before 1900 only 5 percent of American births occurred in hospitals. By 2000, the Centers for Disease Control reported that 99 percent of births did.

What’s wrong with all this? There are many negative effects of the medicalization of birth, but let’s keep it simple. Childbirth is more medicalized now than ever, with more interventions, more drugs, and more surgeries. Our Caesarean section rate is up to around 30 percent, despite World Health Organization recommendations of 15 percent. Are women and babies healthier? Safer? Happier? The answer is no. The United States continues to rank near the bottom of developed countries in relation to infant mortality, coming in second to last in 2006. Experts disagree on why. Some cite sub par health care for low-income pregnant women, while others point to increasingly complicated neonatal surgical interventions for otherwise unviable pregnancies. The simple fact is that Americans have one of the most costly health care systems in the world, but in many respects our health outcomes are nothing to brag about among our developed-world peers.

Beyond all of this, what the birthing rights movement addresses is the narrowing scope of women’s choices about how they give birth. Hospitals and doctors have increasingly specific requirements and regulations about childbirth, many times based on standardized ideas of how a “normal” birth progresses. When women fail to meet these standards, interventions are employed, many of which are costly and cause a landslide of further intervention. Let’s not forget the emotional and psychological component. Many women give birth in environments where they feel unsupported, a fact exacerbated by hospital staffers who are overworked and face increasing productivity demands. They instead rely on family to give emotional support, but not all women have the familial support they need or want.

Birth activism provided me with a new outlet for my feminist politics and a way to support women during an important time in their lives. After a harrowing experience in a public maternity ward in Ecuador, where I briefly lived, I became a doula, accompanying women during labor. Unfortunately, working as a doula—while an incredible opportunity—was not the empowering experience that I had hoped it would be. I found that I had little ability to influence births and I could be in the birthing room only as long as I kept my mouth shut and stayed out of the way. I accompanied four women during their labors and deliveries in this hospital, but by then I was at my breaking point.

Activists working in the abortion-rights field have similar experiences. It is almost impossible for a woman to have an abortion in a totally safe and supportive environment, free from social and familial stigma. No matter how much we pro-choice advocates fight, there will always be a loud and ever-present group on the other side (often just outside the clinic doors) telling women they should feel guilty about their choices and that they are based on selfishness and sin. Women are rarely allowed the freedom to make these choices in the idealistic environment that we abortion-rights advocates dream about, free from the influence of divisive politics. This is where the connection between abortion-rights advocates and birth activists seems exceedingly clear to me: Both are attempts to fight back against rhetoric that prioritizes the unborn fetus instead of the adult woman.

When a woman is giving birth in an American hospital, the doctors, nurses, and extended medical team are almost wholly focused on the status of the fetus inside of her—constantly employing technologies to monitor it and drugs to regulate it, allowing fetal well-being to be their dominant concern. When we think of a woman with an unintended pregnancy (and this could be the same woman, in a different phase of her life), a similar logic applies. Anti-choice activists don’t trust women to make responsible decisions about their lives and ability to parent; they instead focus on the potential life inside a woman, and place all emphasis on the future of the fetus rather than on the future of the woman. Anti-choice activism and overly-medicalized birthing practices are both based on a lack of trust in women. Consider the many restrictions imposed on birthing women: rules regulating out-of-hospital midwives, mandatory waiting periods for abortions, forced C-sections, and biased pre-abortion counseling are all examples of how people do not trust women (or their support networks) to make responsible decisions about family well-being.

What is unique about the role of the doula is that she gets to be one of the only people in the birthing process exclusively focused on the woman. She focuses entirely on how the woman is feeling, providing accompaniment and support through a process that can be scary and lonely, particularly in a hospital. Studies show the positive effect that this kind of unconditional support and attention can have on both the mother and her child. That’s the logic that really connects the birthing and the pro-choice movements—if we support women and their decisions, everyone will fare better, including children.